Governor Signs Montana Medicaid Expansion Renewal Bill

May 10, 2019

New work and public service requirements for certain Medicaid expansion enrollees were signed into state law Thursday.

Gov. Steve Bullock signed a bill to continue and change the health coverage program for low income adults, during a crowded ceremony in the east wing the state Capitol.

"When I first signed Medicaid expansion into law four years ago I said that lives would be changing and lives would be saved," Bullock said.

The reauthorization in the so-called Medicaid Reform and Integrity Act continues the health coverage program for around 96,000 low-income adults in Montana.

Since 2015, when the state expanded Medicaid coverage to adults making less than around $17,000 a year, Montana’s uninsured rate has been cut in half. The policy is also credited by many supporters for keeping rural hospital doors open and allowing other health care providers to give away less care for free.

Bullock had nothing but praise for the law to continue the policy Thursday. However before it reached his desk he called it “imperfect.”

Unlike four years ago, Republican backers of reauthorizing Medicaid expansion were able to include new requirements for some adults enrolled in the program. Those weren’t allowed under the Obama administration, but with Donald Trump in the White House that’s different.

Rep. Ed Buttrey, a Republican from Great Falls, sponsored the bill to continue Medicaid expansion with what he calls “community engagement” requirements.

"'Skin in the game' was always a point that if you benefit from the program, you need to help contribute to the success and funding of the program."

However, the ranks within Montana’s majority party disagreed about what those new work requirements should look like, and some say the rules signed into law Thursday are weak.

Work requirements were flat-out rejected by Montana Democrats early on in the state’s 2019 legislative session. But without support from Republicans to continue the program more or less at status quo, Democrats were forced to vote for the policy or else watch Medicaid expansion expire at the start of July.

Heather O’Loughlin is with the Montana Budget and Policy Center, an organization advocates for social services for low income Montanans. She says the top priority was for lawmakers to reauthorize Medicaid expansion. But with the new work and public service requirements, "It’s important to note that we could see a loss of coverage of those that are currently enrolled accessing health care coverages."

However O'Loughlin says for the vast majority of people on Medicaid expansion, coverage should continue with little change.

An analysis of the reauthorization bill from Gov. Steve Bullock’s office says most of the roughly 96,000 people enrolled in Medicaid expansion will be exempt from the new work requirements.

Of the 8,000 people projected to fall under the new rules rules, about half of them are expected to lose coverage.

"I think that’s a fair assessment given the number of exemptions," O'Loughlin says.

The so-called Medicaid Reform and Integrity Act passed out of the Legislature with unanimous support from Democrats and backing from a centrist group of Republicans.

But conservative Republican leadership in both the House and Senate condemned the bill. Senate Majority Leader Fred Thomas from Stevensville spoke with reporters soon after the policy passed out of the Legislature in mid-April.

"There's a lot of exemptions in it now and it’s not what it ought to be," Thomas said.

Sen. Bob Keenan, a Republican form Bigfork, says the exemptions are broad.

"We have exemptions that nobody would have to be held to community engagement work requirements if they’re in a economically depressed area. Well that’s almost the whole state."

Rep. Buttrey disagrees with that characterization of the requirements. He says most people on Medicaid expansion will be exempt from the 80-hour per month "community engagement" because they’re already working.

After Montana passed Medicaid expansion in 2015, the number of people that signed up for the program was double what state officials first projected. Buttrey points to that past forecasting error when he says the estimates about how many people could be impacted by the new work requirements could also be wrong.

"The only way we’re gonna know is two years from now when we come back and we actually look at how many people fell into that category and how many people were disenrolled. And I don’t think it’s going to be 8,000 and 4,000. It will probably be something quite a bit different."

What that number looks like will be influenced by how Montana’s Department of Public Health and Humans Services (DPHHS) creates the new system for people to report that they’re meeting the work and public service requirements.

The new requirements first need approval from federal Medicaid officials. The law signed Thursday gives DPHHS until the end of August to submit that waiver.

The Trump administration's plans for allowing work requirements for Medicaid expansion enrollees in two other states have been struck down by a federal judge, ruling that they undermine the program’s goal of getting medical coverage to the needy.

Buttrey says similar legal challenges could be coming in Montana.

"And there are going to be, I’m sure, potential court challenges. And we need to let those work through the system like the other states that have had them. But I think we did a great job, a good, responsible conservative solution, probably the best in the nation so far."

The law signed Thursday says Montana’s "community engagement" requirements for certain Medicaid expansion enrollees will go into effect on January 1, 2020.